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ERA Enrollment Form Change or Add a New ERA Please select only one option from below Add a new ERA Change an Existing ERA Setup a new ERA account Delete my ERA Account Add New Billing Provider Remove Existing Billing Provider Provider Organization Organization Name Location Address Street State City Billing Tax ID Zip Billing NPI Rendering NPI Remit Address Provider Email Signature Contact Phone Number Title Date Distribution Method Please indicate the EDI Clearinghouse Name Billing Providers Please check if adding more than one provider Complete and submit the ERA enrollment form the following email ERAenrollment CareCentrix. com All the fields of the form are mandatory. The enrollment form must be signed by an authorized personnel* The form requires only one NPI. Check the box in Billing Providers if you are enrolling more than one NPI. A CareCentrix associate will contact you after submitting the form for further details. com All the fields of the form are mandatory. The enrollment form must be signed by an authorized personnel* The form requires only one NPI. Check the box in Billing Providers if you are enrolling more than one NPI. A CareCentrix associate will contact you after submitting the form for further details.

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